Artéria esfenopalatina: desafio cirúrgico na epistaxe

Clinical Outcomes of Endonasal Sphenopalatine Artery Cauterization in Endoscopic Sinus Surgery

Endoscopic sinus surgery (ESS) is one of the common ENT surgeries performed. Various techniques are available for reducing the blood loss during ESS. The efficacy of cauterization of the SPA in reducing the per-operative blood loss has not been explored in the literature. This study evaluates the efficacy of SPA cauterization prior to sinus surgery and its per-operative and post-operative outcomes. To study the outcomes of endonasal SPA cauterization in patients undergoing ESS. This is a prospective observational study conducted in a tertiary care centre from October 2018 to October 2020. 30 patients underwent ESS where SPA was cauterized by bipolar diathermy in one side of the nasal cavity and in the contralateral side, SPA was not cauterized. The results were tabulated and compared between the cauterized and non cauterized side. p value < 0.05 was considered as statistically significant. Mean blood loss (p value = 0.20), operating time (p value = 0.19), surgical field grade, post operative Lund Kennedy Score at 1st, 4th and 12th week were compared and the difference between cauterized and non cauterized was found to be statistically insignificant. In this study, endonasal SPA cauterization did not significantly reduce the intra operative bleeding and surgical field grade in patients undergoing ESS. SPA cauterization did not adversely affect the per operative and post operative outcome and hence authors highlight the fact that it can be safely performed in cases where severe intra operative bleeding is expected and its effectiveness can be studied better in such cases.

Survey Anatomical Features and Related Factors of the Sphenopalatine Foramen on Computed Tomography

The aim of the research is to define anatomical features of the sphenopalatine foramen (SPF) and be related to the SPF on computed tomography (CT) such as shape, location, size of the SPF, the appearance of the ethmoidal crest, and the distance from SPF to some landmarks in the nasal cavity. As a result, surgeons could quickly determine the SPF location in transnasal endoscopic sphenopalatine artery ligation (TESPAL). A cross-sectional study was conducted. This study was carried out at Cho Ray hospital from August 2019 to June 2020. Image data from 55 patients who had been indicated sinuses CT. Results show that the SPF had a wide range of shapes: oval (20.9%), triangle (19.1%), circle (18.2%), racket shape (7.3%), hourglass shape (6.4%), and other shapes. In the anteroposterior dimension, the mean SPF was 5.72 ± 1.22 mm. In the craniocaudal dimension, the mean SPF measured 5.62 ± 1.99 mm. The SPF was mainly located in the superior meatus and in the transition between the middle and superior meatus. The most reliable anatomical landmark to find the SPF was the ethmoidal crest with an appearance rate of about 95.5%. The mean distances from SPF to anterior nasal spine, nasal floor, nasal septum, maxillary line, anterior head of the middle turbinate, choanal arch, and base lamella were 57.04 ± 3.11, 24.71 ± 2.90, 11.26 ± 2.09, 34.93 ± 2.07, 32.69 ± 3.30, 8.82 ± 1.65, and 8.07 ± 1.28 mm, respectively. CT scan images in this study can provide information about anatomical features of the SPF, which contribute to the quick and efficient identification of the SPF before and during TESPAL.

Etiopathogenic features of severe epistaxis in histological samples from individuals with or without arterial hypertension

There is a consensus that arterial hypertension (AH) is associated with stroke. Therefore, this study aimed to evaluate the histology of the microvasculature associated with the mucosa of the posterior nasal cavity to identify possible factors related to vascular weakening and rupture. Histological sections were obtained from hypertensive and normotensive individuals, regardless of epistaxis. Our results showed that the group with AH had: (a) smaller median diameter of the lumen of arteries and arterioles; (b) increased thickness of the intimal arteries and arterioles, slight inflammatory infiltrate, and rupture of internal elastic lamina; (c) greater thickness of the middle tunica in arterioles; (d) lower percentage of histological sections with non-injured intimal layers in capillaries, arterioles, and small arteries; (e) lower percentage of histological sections with intact media tunic and/or myocytes juxtaposed in arteries and arterioles; (f) no difference between the diameters of small arteries or arterioles. The intima was thicker in individuals with severe epistaxis than in the normotensive group, but it did not differ from the AH group. Thus, hypertension may cause structural lesions in the vascular layers, and in the absence of tissue repair and the persistence of AH, these lesions may favour vascular rupture, especially during hypertensive peaks.

Endoscopic sphenopalatine artery electrocoagulation for refractory epistaxis: a clinical study

BACKGROUND

The electrical coagulation of sphenopalatine artery(SPA) under nasal endoscopy has gradually become an important surgical intervention for epistaxis.

AIM

To investigate the effectiveness and complications of SPA electrocoagulation for epistaxis.

MATERIAL AND METHODS

The clinical data of 47 patients undergoing SPA electrocoagulation were analyzed, retrospectively.

RESULTS

Forty-seven patients were enrolled, with a male to female ratio of approximately 3:1. 11of 36 were under 45 years old, 25 of 36were 45 years old and above. Among female patients, one was under 45 years old, and the others were 45 years old and above, but there was no significant difference in gender composition between different age groups (χ ² = 1.069, p = .301). All patients were unilateral epistaxis. The effective control rates of epistaxis within 24 h after surgery, early postoperative, and late postoperative were 100%, 100%, and 97.9%, respectively. There were 6 patients with complications, including 3 patients with nasal dryness and ecdysis on the affected side, 2 patients with numbness on upper lip, 1 patient with nasal adhesion and pus on affected side.

CONCLUSION AND SIGNIFICANCE

Refractory epistaxis has no relationship with age and sex, SPA electrcoagulation can effectively control refractory epistaxis and is an effective surgical method.

Resection of the ethmoidal crest in sphenopalatine artery surgery

BACKGROUND

In severe cases of epistaxis, in spite of several procedures described in the literature for its management, surgical treatment has been recognized by most authors as 1 of the most effective, especially when it includes ligation and/or electrocoagulation of the nasal branches of the sphenopalatine artery. The objective of this study is to determine the importance of ethmoid crest resection during sphenopalatine artery surgery, in the management of severe epistaxis.

METHODS

We report a double-blinded randomized clinical trial, in which intervention was the ethmoid crest resection during electrocoagulation of the sphenopalatine artery. The study participants consisted of 42 patients with severe epistaxis and indication for surgical treatment, treated at the Otorhinolaryngology Emergency Room (ORL ER) of Hospital Sao Paulo, the teaching hospital of the Federal University of Sao Paulo.

RESULTS

There was significant greater exposure of the arterial branch after removal of the ethmoidal crest (p = 0.009). The rate of bleeding within 48 hours of the procedure was significantly lower in the crest removal group.

CONCLUSION

Resection of the ethmoid crest during sphenopalatine surgery proved to be feasible without additional risks, including promoting decrease in the overall surgical time. It provided better exposure of arterial branches of the sphenopalatine foramen, leading to a lower rebleeding rate within 48 hours.

Sphenopalatine foramen: endoscopic approach with bony landmarks

OBJECTIVE

To establish whether nasal bony landmarks on computed tomography could be utilised reliably in endoscopic approaches to the sphenopalatine foramen.

METHODS

A prospective analysis of 102 consecutive helical computed tomography scans of the paranasal sinuses was carried out by 2 senior ENT surgeons. Distances from the sphenopalatine foramen to endoscopically palpable bony landmarks were measured.

RESULTS

There were a total of 102 patients (45 females and 57 males), with a mean age of 62 years. The mean distance from the posterior fontanelle to the sphenopalatine foramen was 14.1 mm (standard deviation = 2.13). The average vertical distance of the sphenopalatine foramen opening from the bony attachment of the inferior turbinate was 14.13 mm. There were no statistically significant differences between any of these measurements (foramen width p-value = 0.714, distance from fontanelle p-value = 0.43 and distance from inferior turbinate p-value = 0.48).

CONCLUSION

Determination of reliable bony landmarks is clinically useful in endoscopic surgery and can aid identification of the sphenopalatine foramen. The inferior turbinate concha and posterior fontanelle may be used as reliable computed tomography landmarks for endoscopic approaches to the sphenopalatine foramen.

Endoscopic management of posterior epistaxis: a review

The paradigm for the management of epistaxis, specifically posterior epistaxis, has undergone significant changes in the recent past. Recent prospective and retrospective data has shown that the endonasal surgical management of posterior epistaxis is superior to posterior nasal packing and angiography/embolization with regards to various factors including pain, cost-effectiveness, risk and overall control of bleeding. Endonasal endoscopic surgical techniques for posterior epistaxis include direct cauterization and transnasal endoscopic sphenopalatine/ posterior nasal artery ligation or cauterization with or without control of the anterior ethmoidal artery. Despite the evidence provided by the current literature, a universal treatment protocol has not yet been established. This review article provides an up-to-date assessment of the available literature, and presents a structured paradigm for the management of posterior epistaxis.

Anatomical and surgical study of the sphenopalatine artery branches

The sphenopalatine artery gives off two main branches: the posterior lateral nasal branch and the posterior septal branch. From 2007 to 2012 17 patients were treated with cauterization and/or ligature of the sphenopalatine artery with endonasal endoscopic approach. 90 nasal dissections were performed in 45 adult cadaveric heads. We evaluated the number of branches emerging from the sphenopalatine foramen and the presence of an accessory foramen. In the surgery group, we observed a single trunk in 76% of the patients (13/17) and a double trunk in 24% (4/17). We found an accessory foramen in four cases. We obtained a successful result in bleeding control in 88% of the cases. In the cadaver dissection group, 55 nasal cavities had a single arterial trunk (61%), 30 had 2 arterial trunks (33%) and in only 5 nasal fossae we observed 3 arterial trunks (6%). We were able to dissect four accessory foramina. We suggest that in most cases only one or two branches are found in the sphenopalatine foramen.